1. Detect, Protect, Perfect: care of patients with Atrial Fibrillation across Wessex
A report for Wessex AHSN ‘Atrial Fibrillation: Detect, Perfect, Protect’ Programme
Dr Anastasios Argyropoulos
Centre for Implementation Science
Wessex AHSN Atrial Fibrillation Senior Programme Manager: Vicki Rowse
Wessex AHSN Atrial Fibrillation Clinical Lead: Sharron Gordon

2. Contents Introduction page 2 Detect page 3 Protect page 12
Perfect page 27
Summary of opportunities page 33
Clinical impact of planned interventions page 34
Cost impact analysis page 37
Appendix A: Data definitions, description-methodology page 40
Appendix B: Cost impact analysis Year 1,Year 2 and Year page 47
References page 50

3. Introduction Atrial Fibrillation
Atrial Fibrillation (AF) is the most common sustained cardiac arrhythmia affecting 1-2% of the UK population. AF becomes more common with increasing age, affecting approximately 10% of the population over 75 years old and 18% of those over 85 years old.
AF is associated with a 5-fold increased risk of stroke compared to other stroke causes. Clinical outcomes in terms of increased disability, are considerably worse for AF-associated compared to stroke not associated with AF, and mortality from stroke is doubled in patients with AF.  Overall 15% of strokes are caused by AF but AF is the predominant cause of stroke in the elderly which is clearly of concern with an ageing patient demographic.
Bed days for patients with a primary or secondary diagnosis of AF are estimated to have cost the NHS £2.8 billion in 2005 in direct care costs with wider costs in terms of lost productivity and social care amounting to an additional £4.2 billion. [1]-[3]

4. DETECT Detection- Key Findings Evidence
Increasing the detection of AF should result in increased anticoagulation rates and a reduction in stroke rates as a consequence. Detection rates are increasing across the region but 21,043 potential AF patients remain to be found across Wessex.
Evidence
Actual vs expected AF prevalence
Percentage of practices uploading GRASP-AF [6] data
AF prevalence
Patients potentially undiagnosed with AF in
AF related strokes

5. 1. Detect

6. 1. Detect
The diagnosis of AF has increased across all CCGs, slowest rates of detection are in Isle of Wight, Southampton, Portsmouth and Wiltshire.

7. 2. Detect
Uploading GRASP AF data to chart online enables review of AF activity in a timely manner. Rates have increased across all CCGS where GRASP AF is in use (Data were not available for IOW & Wiltshire). All CCGs need to reach 90% in order to allow confident monitoring of AF data.

8. 3. Detect

9. 3. Detect

10. 4. Detect
Prevalence is increasing across all CCGs. The rate of identification is slower in some CCGS and support maybe required to increase identification rates.

11. 5. Detect
As processes improve in delivering consistent review and anticoagulation of patients with AF the rates of stroke reduce. Stroke rates are reducing in some CCGs.

12. 5. Detect

13. PROTECT Protection- Key Findings Evidence
Anticoagulation reduces the risk of AF related stroke by 66% therefore increasing the rates of anticoagulation will result in reduced stroke rates. Anticoagulation rates are increasing across Wessex.
Evidence
Patients diagnosed AF missing a risk assessment
Patients treated with anticoagulation
Patients treated with anticoagulation drug therapy with CHA2DS2-VASc≥ 2
Patients risk assessed and eligible for treatment not on anticoagulant
Patients contraindicated or declined anticoagulation
Patients treated with antiplatelets solely
AF related stroke patients not on anticoagulants

14. 1. Protect

15. 1. Protect

16. 2. Protect

17. 2. Protect

18. 3. Protect

19. 3. Protect

20. 4. Protect

21. 4. Protect

22. 5. Protect
Patients are contraindicated or declined anticoagulation where treatment is seen as inappropriate. In some cases exclusion maybe inappropriate and based on a lack of clinical expertise. Rates of exclusion are declining across all CCGs in Wessex but exclusion rates are higher than the national average.

23. 5. Protect

24. 6. Protect
Antiplatelet medicine was historically viewed as an appropriate therapy for AF related stroke. Increased understanding now guides anticoagulation as the best treatment and antiplatelet use is reducing year on year in all CCGS in Wessex

25. 6. Protect

26. 7. Protect
As more patients are identified within the population and reviewed for anticoagulation less patients should present with a stroke where AF was known but untreated. 3 CCGs in Wessex have data sets showing an increase in numbers, this needs to be investigated.

27. 7. Protect
Our target aim for anticoagulation in AF is that 85% of patients will receive treatment

28. PERFECT Perfection- Key Findings Evidence
Between 30-50% of patients do not take their medicines as intended. This results in up to £150 million or avoidable medicines waste in the NHS and poor patient outcomes. The New Medicines Service (NMS) provides support for people with long-term conditions newly prescribed anticoagulation to help improve medicines adherence.
Increasing NMS discussions will increase adherence by at least 10% 
Evidence
Anticoagulant or antiplatelet MUR
Anticoagulant or antiplatelet NMS
Treated patients without adequate anticoagulation

29. 1. Perfect
MUR reviews represent an annual opportunity to assess adherence, drug interactions and assess risk / benefit. An increase in reviews is desirable but these reviews are reducing across Wessex.

30. 1. Perfect

31. 2. Perfect
NMS provides an excellent opportunity to assess side-effects, explain the risks and benefits and offer support to patients newly initiated on anticoagulation to. Rates are increasing in the majority of CCGs in Wessex.

32. 2. Perfect

33. 3. Perfect

34. SUMMARY OF OPPORTUNITIES
4. Detect | 1. Protect | 4. Protect | 3. Perfect

35. CLINICAL IMPACT OF PLANNED INTERVENTIONS
Key Findings
A potential total number of 32,214 patients should be identified and treated across Wessex:
10,522 patients potentially undiagnosed with AF
1,829 patients diagnosed AF missing a risk assessment
9,589 patients assessed and eligible for treatment not on anticoagulant
10,274 patients likely to be receiving inadequate anticoagulation
Evidence
Clinical impact of planned interventions
Clinical impact of planned interventions preventable strokes & major bleeds

36. CLINICAL IMPACT OF PLANNED INTERVENTIONS

37. CLINICAL IMPACT OF PLANNED INTERVENTIONS

38. COST IMPACT ANALYSIS Key Findings Evidence
Total potential 3-year savings in direct medical costs of approximately £2.9m are achievable across Wessex.
Total potential 3-year savings including social care costs of approximately £44.17m are achievable across Wessex.
Evidence
Cost impact analysis year 1
Cost impact analysis year 2
Cost impact analysis year 3
Cost impact analysis years 1-3
Cost impact analysis summary

39. COST IMPACT ANALYSIS: years 1-3

40. COST IMPACT ANALYSIS: summary

41. Appendix A: Data definitions, Description-Methodology (1/7)
DETECT
Actual vs expected AF prevalence
Actual AF prevalence was obtained from [4],[5]
CCG list sizes were obtained in 5-year age bands from [6],[7]
Age-sex specific prevalence rates of AF in 2010 were obtained from [8] (Table A1) and were applied to each CCG population to derive the expected AF prevalence
Percentage of practices uploading GRASP-AF data
Number of GP practices uploading GRASP-AF data [9] divided by the total number of GP practices per CCG [4],[5],[10].
AF prevalence
Percentage of patients with known AF [9].
Patients potentially undiagnosed with AF
Expected AF population (from 1. Actual vs expected AF prevalence)
Actual AF population (from 1. Actual vs expected AF prevalence)
Percentage
Number of patients
(a-b)/a
a-b
AF related strokes
Percentage of patients with AF before stroke. Item reference F6.3 obtained from [11].

42. Appendix A: Data definitions, Description-Methodology (2/7)
Age group
(years)
Male
Female
Population (n)
Af (n)
Prevalence (%)
0-19
8,894
8,394
20-29
4,389 4
0.1
3,804
30-39
4,445 15
0.3
4,076
40-44
2,502 26
1.0
2,360 1
45-49
2,483 22
0.9
2,417
0.2
50-54
2,575 53
2.1 10
0.4
55-59
2,710 86
3.2
2,549 17
0.7
60-64
2,736
115
4.2
2,596 43
1.7
65-69
2,383
164
6.9
2,450 83
3.4
70-74
1,874
212
11.3
1,957
112
5.7
75-79
1,405
228
16.2
1,797
183
10.2
80-84
1,015
206
20.3
1,478
231
15.6
85-89
549
126
23.0
924
180
19.5
90-94
157 44
28.0
355
24.2
95-99 24
16.7 67 14
20.9
100+
25.0
All
38,142
1,305
37,803
969
2.6
Table A1 Prevalence of AF for men and women in the Skellefteå region in 2010 according to age [8]

43. Appendix A: Data definitions, Description-Methodology (3/7)
PROTECT
Patients diagnosed AF missing a risk assessment
Patients with atrial fibrillation in whom stroke risk has been assessed using the CHA2DS2-VASc score risk stratification scoring system in the preceding 12 months (excluding those patients with a previous CHADS2 or CHA2DS2-VASc score of 2 or more). AF006- Denominator plus Exceptions, obtained from [4],[5]
AF006- Numerator [4],[5]
Patients without current CHA2DS2-VASc score: a-b
Percentage
Number of patients
(c/a) × 100
c × (assumes that 84.2 % of patients have CHA2DS2-VASc score of 2 or more [12])
Patients treated with anticoagulation
Percentage of high risk patients treated with anticoagulation [9].
Patients treated with anticoagulation drug therapy with CHA2DS2-VASc ≥ 2
In those patients with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more, the percentage of patients who are currently treated with anti-coagulation drug therapy. AF007- Patients receiving intervention (per cent), obtained from [4],[5].
Patients risk assessed and eligible for treatment not on anticoagulant
In those patients with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more, the percentage of patients who are currently treated with anti-coagulation drug therapy. AF007- Denominator plus Exceptions, obtained from [4],[5]
AF007- Numerator [4],[5]
((a-b)/a) × 100
a-b
Patients contraindicated or declined anticoagulation
Percentage of high risk patients contraindicated or declined anticoagulation [9].
Patients treated with antiplatelets solely
Percentage of high risk patients treated with antiplatelets solely [9].
AF related stroke patients not on anticoagulants
Percentage of patients with AF before stroke not on anticoagulant medication. Item reference F6.14 obtained from [11].

44. SUMMARY OF OPPORTUNITIES
Appendix A: Data definitions, Description-Methodology (4/7)
Definition
Description- Methodology
PERFECT
Anticoagulant or antiplatelet MUR
Percentage of MUR patients on anticoagulant or antiplatelet medication [13].
Anticoagulant or antiplatelet NMS
Percentage of NMS patients on anticoagulant or antiplatelet medication [13].
Treated patients without adequate anticoagulation
AF007- Numerator [5]
Oral Anticoagulants % items obtained from [14] for January March 2017
Patients currently treated with novel oral anticoagulant (NOAC): a × b
Patients currently treated with warfarin: a-c
Assumptions
Proportion of warfarin patients with Time in Therapeutic Range (TTR)> 65%: 60%
Proportion of NOAC patients adequately anticoagulated: 95%
Percentage
Number of patients
1- [( (d × i)+(c × ii) )/ a ]
a- [ (d × i)+(c × ii) ]
SUMMARY OF OPPORTUNITIES
4. DETECT | 1. PROTECT | 4. PROTECT | 3. PERFECT

45. CLINICAL IMPACT OF PLANNED INTERVENTIONS
Appendix A: Data definitions, Description-Methodology (5/7)
Definition
Assumptions
CLINICAL IMPACT OF PLANNED INTERVENTIONS
1. Clinical impact of planned interventions
Anticipated impact of planned interventions
Assumptions regarding the percentage of patients in each gap who will be potentially identified and treated [15]:
4. DETECT: 50%
1. PROTECT: 90%
4. PROTECT: 80%
3. PERFECT: 80%
Anticipated timescale for planned activities
Assumptions regarding the timescale over which intervention will be made [15]:
4. DETECT: 12 months
1. PROTECT: 12 months
4. PROTECT: 12 months
3. PERFECT: 12 months
It is assumed that patients will be targeted at a uniform rate over the course of the intervention period.
It is assumed that clinical benefits will be accrued in a linear fashion over the course of treatment.
The number of patients identified in each gap (Summary of opportunities: 4. DETECT| 1. PROTECT| 4. PROTECT| 3. PERFECT) multiplied by the percentage of patients in each gap who will be potentially identified and treated.
Clinical impact of planned interventions preventable strokes & major bleeds
Clinical assumptions for impact assessment
Annual risk of stroke:
Untreated: 5.82% [12], [16],[17]
Warfarin: 2.09% [12], [16]-[18]
NOAC: 1.52% [12], [16], [17], [19], [20]
Annual risk of major bleed [12], [16]-[18]:
Untreated: 0.49%
Warfarin: 1.07%
NOAC: 1.02%
Default assumptions [15]:
Unidentified patients have the same CHA2DS2-VASc profile as known population
All new patients will be adequately anticoagulated
Patients inadequately anticoagulated at baseline will have baseline risk of stroke and major bleed
90% of inadequately anticoagulated patients will switch to NOAC

46. Appendix A: Data definitions, Description-Methodology (6/7)
Cost-inputs
COST IMPACT ANALYSIS
Cost inputs for impact assessment
Year 1 cost of stroke care: £12,228 [12], [17], [21]
Year 2+ cost of stroke care: £2,430 [12], [17], [21]
Cost of major bleed: £1,173 [12], [17]
Cost of screening for AF (per patient screened): £16.34 [22]
Annual cost of treatment for Warfarin (drug cost): £41.32 [12]
Annual cost of treatment for Warfarin (monitoring): £242 [12], [17]
Annual cost of treatment for NOAC: £ [14], [23]
Social care cost estimation
Stroke savings including social care costs calculations were based on the ratio of direct care costs to social care costs as reported in [21].
Assumptions- Limitations
Planned future changes to NOAC use [15]
Projected percentage of NOAC use for year 1, year 2 and year 3 for new patients was assumed to be equal to the Oral Anticoagulants % items for each CCG obtained from [14] for January March 2017.
Projected percentage of NOAC use for each CCG for year 1, year 2 and year 3 for patients inadequately anticoagulated was assumed to be 90%.
The impact of switching therapy for existing stable patients is not taken into consideration.
Year 1, year 2 and year 3 cost impact analysis
Expected AF not identified costs are subject to considerable uncertainty due to the fact that expected AF was calculated using age-sex specific prevalence rates of AF in 2010 [8] (Table A1).

47. Appendix A: Data definitions, Description-Methodology (7/7)
COST IMPACT ANALYSIS
Cost impact calculation
4. Detect. Patients potentially undiagnosed with AF are used to evaluate [15]:
The cost of screening for patients in the current population (>65 years of age)
The additional cost of treating the newly identified patients at year 1, year 2 and year 3, based on the current warfarin/NOAC use
The total cost of a major bleed in patients started on anticoagulant
The cost impact on improved stroke prevention at year 1, year 2 and year 3, if all patients were to receive effective anticoagulation
1. Protect. Patients diagnosed AF missing a risk assessment [15]:
The additional cost of treating the newly risk-assessed patients who qualify for anticoagulation
The cost impact on improved stroke prevention at year 1, year 2 and year 3, if all patients were to receive effective anticoagulation, and continue on treatment with adequate compliance
4. Protect. Patients assessed and eligible for treatment not on anticoagulant [15]:
The anticipated additional year 1 cost of treating patients who are not currently anticoagulated. This assumes warfarin and NOAC treatment patterns remain consistent with the currently treated local AF population. The initiation of NOAC therapies in patients who have previously declined warfarin are accounted for in the population
The total anticipated cost of a major bleed in patients started on anticoagulant
The potential cost impact on improved stroke prevention at years 1, 2 and 3, if all patients were to receive effective anticoagulation and continue on treatment with adequate compliance.
3. Perfect. Treated patients without adequate anticoagulation [15]:
The anticipated additional cost of changing treatment in inadequately treated patients. This assumes 25% of warfarin-treated patients will switch to a NOAC and 20% will increase their warfarin costs for the subsequent year to reflect a higher dose
The total anticipated cost of a major bleed in patients started on adequate anticoagulation. It is assumed that inadequately treated patients will have had the same risk of bleed as an untreated patient
The potential cost impact on improved stroke prevention at years 1, 2 and 3, if all patients were to receive effective anticoagulation, and continue on treatment with adequate compliance. It is assumed that inadequately treated patients will have the same risk of stroke as an untreated patient

48. Appendix B: Cost Impact Analysis Year 1

49. Appendix B: Cost Impact Analysis Year 2

50. Appendix B: Cost Impact Analysis Year 3

51. References
[1] NHS Improving Quality. Costs and benefits of Antithrombotic Therapy in Atrial Fibrillation in England: An economic Analysis Based on Grasp AF. March Available from:
[2] Wessex Academic Health Science Network. Atrial Fibrillation Programme Newsletter. January Available from:
[3] Anticoagulation Europe (UK), Atrial Fibrillation Association. The AF Report-Atrial Fibrillation: Preventing A Stroke Crisis Available from: strokecrisis.org/files/files/The%20AF%20Report%2014%20April% pdf
[4] NHS Digital. Quality and Outcomes Framework (QOF) Accessed November Available from:
[5] NHS Digital. Quality and Outcomes Framework (QOF) Accessed November Available from:
[6] NHS Digital. Number of Patients Registered at a GP Practice (practice level, 5 year age groups) - April Accessed November Available from:
[7] NHS Digital. Number of Patients Registered at a GP Practice (practice level, 5 year age groups) - April Accessed November Available from:
[8] Norberg J, Bäckström S, Jansson J-H, Johansson L. Estimating the prevalence of atrial fibrillation in a general population using validated electronic health data. Clinical Epidemiology. 2013;5: doi: /CLEP.S53420.
[9] PRIMIS and NHS England. Guidance on Risk Assessment and Stroke Prevention in Atrial Fibrilation (GRASP-AF) tool. Data extract received in September 2017: audits/grasp-af.aspx
[10] NHS Digital. Quality and Outcomes Framework (QOF) Accessed November Available from:
[11] Royal College of Physicians. Sentinel Stroke National Audit Programme (SSNAP), Clinical Audit. Accessed November Available from:
[12] National Institute for Health and Care Excellence. Atrial fibrillation: management - Clinical guideline (CG180) - costing template. June Available from: template
[13] NHS Business Authority. Medicines Use Review (MUR)/New Medicine Services (NMS) quarterly submission. Data extract received in August Data submission details available at:
[14] NHS Business Services Authority. Medicines Optimisation CCG Dashboard. Accessed November Available from:
[15] Greater Manchester Academic Health Science Network, JB Medical, Public Health England. Atrial Fibrillation Budget Impact Model. Accessed November Available from:
[16] National Institute for Health and Care Excellence. Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation (TA249) - costing template. March Available at:
[17] National Institute for Health and Care Excellence. Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation (TA256) - costing template. March Available at:
[18] Hart R, Pearce L, Aquilar M. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007;146:857-67
[19] Patel M, Mahaffey K, Garg J et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365:883-91
[20] Connolly S, Ezekowitz M, Yusuf S et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:
[21] Youman P, Wilson K, Harraf F, Kalra L. The economic burden of stroke in the United Kingdom. Pharmacoeconomics 2003;21 Suppl1:43-50
[22] Hobbs F, Fitzmaurice D, Mant J et al. A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening)
versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Health Technol Assess 2005;9:1-74
[23] British Medical Association and Royal Pharmaceutical Society. BNF 72 September 2016-March 2017